<style>
	div.enrollment-menu
	{
		padding:20px;
		<!--border:2px dashed #c0c0c0;-->
	}
	div.option{
		margin:20px 5px;
	}
	ul li{
		list-style:none;
	}
	span{
		padding:0px;
		margin:0px;
		font-size:15px;
		color: #4d4d4d;
	}
	form.custom .custom.checkbox.checked:before {
    content: "\2714";
	cursor: pointer;
	}
</style>

<?php
$this->load->view('enrollment/enrollment_modal');
$genderAttrib = array('' => 'Select Gender...', 'male' => 'Male', 'female' => 'Female' );
$child_birth_position = array('first'=>'First','Second'=>'Second','third'=>'Third','fourth'=>'Fourth','fifth'=>'Fifth','sixth'=>'Sixth','youngest'=>'youngest','only'=>'Only');
?>
<div class="row">

<div class="large-1 columns">&nbsp;</div>
<div class="large-10 columns enrollment-menu content-views">

<input type="button" value="Step 3: Authorization" class="btn btn-large btn-success" style="width:100%;">

<div>&nbsp;</div>

<? echo $system_message;?>
<?echo form_open('let_be','id="check-form-submit" class="custom" data-abide autocomplete="off"');?>

	<div class="large-12 columns"><h5 class="lead">AUTHORIZATION</h5></div>
	
	<hr class="clearfix">
	
	<div class="large-12 columns">
		<span>I give consent for my child to receive the following:</span>
	</div>
	<div class="clearfix"></div>
	<div class="large-12 columns">
		<div class="large-2 columns">
			&nbsp;
		</div>
		<div class="large-5 columns">
			<span>*1. Minor first aid</span>
		</div>
		<div class="large-2 columns">
			<?=form_radio('authfirst_aid', 'no','checked');?> No <?=form_radio('authfirst_aid', 'yes');?> Yes
		</div>
		<div class="large-3 columns">
			&nbsp;
		</div>
	</div>
	<div class="clearfix"></div>
	<div class="large-12 columns">
		<div class="large-2 columns">
			&nbsp;
		</div>
		<div class="large-5 columns">
			<span>*2. Emergency care</span>
		</div>
		<div class="large-2 columns">
			<?=form_radio('auth_emergency', 'no','checked');?> No <?=form_radio('auth_emergency', 'yes');?> Yes
		</div>
		<div class="large-3 columns">
			&nbsp;
		</div>
	</div>
	<div class="clearfix"></div>
	<div class="large-12 columns">
		<div class="large-2 columns">
			&nbsp;
		</div>
		<div class="large-5 columns">
			<span>*3. Emergency care at the nearest hospital</span>
		</div>
		<div class="large-2 columns">
			<?=form_radio('auth_emergency_nearest_hosp', 'no','checked');?> No <?=form_radio('auth_emergency_nearest_hosp', 'yes');?> Yes
		</div>
		<div class="large-3 columns">
			&nbsp;
		</div>
	</div>
	<div class="clearfix"></div>
	<div class="large-12 columns">
		<div class="large-2 columns">
			&nbsp;
		</div>
		<div class="large-5 columns">
			<span>*4. Oral non-prescription medication</span>
		</div>
		<div class="large-2 columns">
			<?=form_radio('auth_oral_non_presc', 'no','checked');?> No <?=form_radio('auth_oral_non_presc', 'yes');?> Yes
		</div>
		<div class="large-3 columns">
			&nbsp;
		</div>
	</div>
	<div class="clearfix"></div>
	<div>&nbsp;</div>
	<div class="large-12 columns">
		<span style="font-align:left;">***NOTE: If you answered "NO" to numbers 1, 2, and / or 3, you must provide the school with alternative emergency care instructions, to be kept in your child's school records / file.</span>
	</div>
	<div class="clearfix"></div>
	<div>&nbsp;</div>
	<div class="large-12 columns">
		<?=form_error('first_permission').'<br/>';?>
		<?=form_checkbox('first_permission', 'yes');?>&nbsp;&nbsp;<span style="font-style:italic;">Permission is hereby given for emergency measures to be initiated in case of accident or sudden illness with the undestanding that I will be notified as soon as possible.</span>
	</div>
	<div class="clearfix"></div>
	<div>&nbsp;</div>
	<div class="large-12 columns">
		<?=form_error('second_permission').'<br/>';?>
		<?=form_checkbox('second_permission', 'yes');?>&nbsp;&nbsp;<span style="font-style:italic;">I certify that all information given is complete and correct.</span>
	</div>
	<div class="clearfix"></div>
	<div>&nbsp;</div>
	<div class="large-12 columns">
		<?=form_error('third_permission').'<br/>';?>
		<?=form_checkbox('third_permission', 'yes');?>&nbsp;&nbsp;<span style="font-style:italic;">I acknowledge that it is my responsibilty to inform Westfields IS of any changes in my child's health, physical condition or medical needs and any changes in our address and / or contact number(s).</span>
	</div>
	<div class="clearfix"></div>
	<div>&nbsp;</div>

	<hr class="clearfix">
	
	<div>
		<input type="hidden" name="let_be_lefg" value="<?=$token;?>">
		<input type="hidden" name="fillup_let_be" value="true">
		<input type="submit" name="fillup_let_be" value="Finish" class="btn btn-primary">
	</div>
<?php echo form_close(); ?>

</div>
<div class="large-1 columns">&nbsp;</div>
</div>